Case Description
A 36-year-old African American female with history of systemic sclerosis and refractory GERD status post RYGB presented to her primary care provider with complaints of daily nausea, non-bloody emesis, dysphagia, and abdominal pain refractory to all medical therapy. Patient had undergone endoscopic evaluation multiple times for this complaint initially limited to the gastric pouch secondary to surgical anatomy with no abnormalities noted. Laboratory analysis was notable for normal CBC, CMP, negative serologic and stool Helicobacter pylori antigen testing. The patient was referred back to gastroenterology for repeat upper endoscopic evaluation. The gastric pouch was notable for diffuse edema, punctate erythema, and friability (Figure 1) . Biopsies demonstrating chronic gastritis with extra-nodal marginal zone lymphoma of MALT type (Figure 2, 3) . A single balloon enteroscopy was then performed for evaluation with biopsies obtained of the gastric remnant. Similar gross findings were seen in the gastric remnant, however, biopsies showed dense lymphoid infiltrate consistent with MALT lymphoma. All biopsies were negative for H. pylori by immunohistochemical stains. Previous biopsies prior to RYGB surgery were reviewed and confirmed to be negative for H pylori infection as were serologic and stool antigen tests.
The patient was diagnosed with H pylori negative gastric MALT lymphoma, Lugano stage I, Ann Arbor IE. The case was discussed with a multi-disciplinary team including medical and radiation oncology. After discussion with the patient, the decision was made to treat with rituximab given the risk of large field radiation and her underlying systemic sclerosis. Repeat endoscopy with biopsy after 4 weeks of treatment showed no appreciable gross or histologic changes. Having failed immunosuppressant therapy, patient was initiated on radiation therapy for a total dose of 30 Gy. On follow up symptoms had improved; repeat single balloon enteroscopy showed mucosal improvement. Biopsies were notable for focal atypical lymphoid infiltrate with monocytoid cytomorphology and focal lymphoepithelial lesion formation, compatible with focal, residual marginal zone lymphoma (partial histologic regression). The amount of atypical lymphoid infiltrate was too small for further assessment by immunohistochemistry. Repeat endoscopy was planned within the next three months but unfortunately with the advent of COVID patient was lost to follow up.